Bravo! Peter Carmel
words by Barbara Hurley / photographs by John Emerson
ake the elevator to the eighth floor of the Doctors Office Center on the Newark campus. Walk through the glass doors into the Neurological Institute of New Jersey and into a world where hope and optimism are surprisingly palpable. You can see it in the broad smile of a young boy who laughs accompanied by the beat of his crutches on the floor. In the calm demeanor of a mother with her arms around the daughter who eight years ago had a tumor removed from her brain. In the determined confidence of the old man struggling to round the corner with his walker. What they share is the knowledge that they are in the hands of outstanding neurosurgeons. Peter Carmel built it, and they came.
Peter Carmel, MD, is professor and chair of the Department of Neurological Surgery at NJMS. He’s co-medical director of the Neurological Institute of New Jersey. This distinguished neurosurgeon has been honored and feted as a visionary professional in every imaginable way, culminating in his selection as the next president of the American Medical Association — the first neurosurgeon to hold that post. The foundation of the department he built was his own sterling reputation as a
pioneer neurosurgeon. His technical expertise is an important half of the story; the other is just as fascinating — the remarkable people skills that not only help him secure favorable outcomes for his patients and but also work the deals that brought his vision of a new kind of departmental organization to fruition.
First his patients. The awards and honors notwithstanding, “changing lives” is how Peter Carmel sees his mission as a neurosurgeon. And for him it has a deeper meaning. “Many people think the best doctor is the one who knows the most,” he explains. “But what good is knowledge without empathy.” Developing personal relationships with patients and helping them overcome incredible obstacles, Carmel believes, are some of the most rewarding experiences a person can have. And he has had his share.
One evening not so long ago, his office phone rang. A woman sounded a bit
desperate and somewhat embarrassed as she asked if Carmel remembered her, “John’s mother.” Of course, he did. John was the poster boy, along with Carmel, for a successful patient story ad campaign from several years back. A framed copy of the ad hangs on Carmel’s office wall. John was 12 years old when Carmel removed an intra- ventricular tumor from the boy’s brain. John, now in his early thirties, was getting married and wanted “his Dr. Carmel” at the wedding. And he did, traveling to a small New Jersey town to reunite with John after 17 years and to toast the bride and groom. “Let me tell you,” Carmel notes, “you don’t get to make that kind of an impact in many jobs.”
He apparently had his eye on this “job” early on, although his career path meandered a bit. Maybe it was because his father was a physician, but there never was a time when this boy growing up in Brooklyn didn’t think that he would be a doctor. Not even when he discovered he hated the sight of blood. Yes, there was that time when, after viewing an especially gory film at a pre-med society meeting in college, he staggered to the outer hallway for some air only to find himself passed out on the floor. “One of my first challenges was anatomy,” he recalls. “First the cadaver, and later the real deal during surgery.” And he remembers the “oh my god feeling” when his first clinical rotation in surgery was scheduled. But at surgery he became so interested in the structures of the body and in the surgical process itself that he quickly, and fortunately, forgot about the blood.
Carmel started his journey through NYU School of Medicine wanting to be a psychiatrist. He became unhappy with that discipline during his second year when he took a course called Introduction to the Patient. In this case, the patient was a young woman who was the subject of a psychiatric interview by the highly regarded psychiatrist teaching the class. Afterwards, the instructor asked the chief resident in psychiatry to give his assessment. “But I didn’t agree with his evaluation and shared my own thesis with the professor,” Carmel remembers. “He told me that my theory was more plausible but both interpretations were acceptable.” Carmel wanted definite answers; but the only one he got was that psychiatry often offered ambiguity, not clarity. And so, based on his continued interest in the central nervous system, he took a detour into neurology, not yet knowing that this would not be his final destination.
A stop along the way was Bellevue Psychiatric Hospital in New York where Carmel earned his room and board during medical school by working up patients. In fact, he lived in a room on the top floor of the hospital that he managed to keep through his surgical internship. The hospital had no neurology residents, so senior medical students were called on to do the patient histories and physicals. Since he was literally a resident, he often chose to accompany his patients into surgery. These excursions stoked the passion that Carmel would discover for neurosurgery.
He remembers vividly the chief resident in neurosurgery at Bellevue at the time, Dr. Amilear Rojas. He had a great influence on Carmel and together they were often off to the OR at night. “He gave me the simple dictum that all neurosurgeons need to know,” Carmel laughingly relates in his best Spanish accent: “‘Don’t put your fingers in the brain.’” He went on to choose neurosurgery and did a residency at the Neurological Institute of New York where he discovered a second passion — dealing with pediatric problems.
And finally we come to the department he created at UMDNJ. Carmel came to the University in 1994 after 31 years at Columbia, where he was founding chief of the division of pediatric neurosurgery and professor of neurological surgery and gained a national reputation as a noted clinician. His ultimate goal was to build his own neurosurgery program. He discovered, however, that New York was saturated when it came to neurosurgery programs, whereas New Jersey had none.
And so when he answered the plea to come here, it was especially appealing to envision filling a void. UMDNJ’s University Hospital needed residents to service its Level 1 trauma center. Carmel needed this door to open.
With his experience in academic medicine, Carmel understood the organizational principle that lined neurosurgery up as a division of general surgery when he arrived. In fact, he was the “first recruit” of Ed Deitch, MD, who had just joined NJMS as the chair of surgery. But no organizational chart was to stand in the way of Carmel’s vision of a division becoming a department with a fully approved residency program. Quite simply, as Carmel explains it, departments – not divisions – get the financial wherewithal to grow. And so this consummate deal-maker made a bargain with the medical school dean at the time: as soon as Carmel developed the neurosurgery residency, the division would become its own department.
Most thought “slim chance.” They were wrong. In 1995 the first site visit yielded probationary approval; in 1996 full approval; and in the summer of 1997, neurosurgery became a department.
The usual model for a neurosurgery department at that time was a group of four doctors, each seeing every patient for one week and spending three weeks in the lab. So each physician in theory could treat any neurological condition. Carmel’s vision was far from the usual. It was “glaringly rare,” according to Carmel, to have physicians with single expertise, even as neurosurgery itself expanded exponentially with the introduction of new techniques and technology.
Every member of his team would have one area of expertise, and the department would do what was necessary to let them become experts. For the first two years Carmel sent each faculty member away for six months of “fellowship training” while continuing their salaries. Clinical income would be shared just as the expertise would ultimately be.
Carmel insisted that his “experts” give papers at important conferences so that they would become the nationally recognized go-to people in their fields. Carmel himself became a referral source. He often had a waiting list of more than five months, but he could now confidently refer some of those hoping to see him to the appropriate expert.
Carmel considers teaching his faculty and shaping his team one of his main functions as department chair. Now, there are five members of his faculty team: Chirag Gandhi, Ira Goldstein, Robert Heary, James Liu, and Charles Prestigiacomo, each one with a specific area of neurosurgical expertise.
Carmel is proud to note that his team will see any tertiary neurosurgery case from anywhere in New Jersey. In fact, they are the only ones who will see elective Medicaid pediatric patients from any corner of the state. “We don’t look at insurance,” Carmel says, “only need.” Besides, what he clearly sees as a “moral obligation” he understands are cases needed by his clinicians to maintain their professional edge.
His department has grown in direct proportion to his willingness to embrace what is new and innovative. One example: Carmel brokered a deal with an Israeli company to test a low field intraoperative MRI. “The machine gives a low resolution image but makes it easy to see if the surgeon got out all the tumor, for example,” he explains. In fact the company engineer lived in Newark and worked with Carmel’s team. The neurosurgeons published papers comparing the new MRI to existing technology, while the company incorporated their suggestions to improve the product. In exchange, UMDNJ got the prototype of the next generation of scanners. That machine is housed in Room 5 at University Hospital.
In August 2010, Carmel was invited to address the incoming class of the University of Texas Southwestern Medical School at an event sponsored by the Dallas County medical society. His speech was published online by Vital Speeches of the Day, which, its web site maintains, gives you an unbiased look at the most important speeches and the finest examples of rhetoric by those who have attained leadership in their fields. Carmel joined the ranks of Barack Obama, Bill Clinton, and other notables whose words have been featured. His words to the fledgling physicians included advice to make decisions not with the mind, but with the gut and heart. “Figure out what excites you and do it,” he urged. “When you love what you do, it’s not work.”
Carmel loves to talk, to tell stories. Even after many, many years in the field, he exudes the enthusiasm and energy that one might expect of a first year medical student. He loves his life, obviously. He will be back and forth to Washington as president of the AMA, the culmination of 25 years at various levels of AMA leadership. But he is the quintessential New Yorker, living in an historic Manhattan building with his wife, a neuroradiologist, within city blocks of his three sons and seven grandchildren. His son Jason is on the pediatric neurological faculty at Cornell Medical School and the Burke Institute.
Carmel collects old medical books; two arrive in his office as he speaks. And he is an active member of the New York and Brooklyn historical societies. Now he has made his own history.
Outstanding Students, Outstanding Residents
UMDNJ tied with Johns Hopkins for second place among U.S. medical schools matching the most students into neurosurgery residency — a resounding
By all measures, neurosurgery historically is one of the most competitive residency programs in the U.S. But the AANS notes a disturbing decline in the number of medical students choosing neurosurgery as a specialty. It reports that, although neurosurgery retains the allure of a fascinating and challenging specialty and continues to attract top students, the increasing influence of work-life balance issues is a deterrent for many. In addition, medical students are rarely introduced to this specialization during their first two years of study, when many choose their future fields; and some never “elect” a neurosurgery rotation in their last two years of medical school.
Right now, the number of Board certified neurosurgeons in this country is less than 3,500 and they are taking care of a population numbering more than 300 million. And as the population ages, the need for their services is increasing. So how to attract future neurosurgeons?
The AANS study asked the residency program directors at eight medical schools, including UMDNJ, how they are encouraging interaction between preclinical medical students and neurosurgeons. The survey identified four key actions likely to strengthen this connection: mentorship programs, faculty lectures, interest groups, and research opportunities. UMDNJ hits three of the four, and Carmel himself has personally mentored students interested in this specialty.
Chirag D. Gandhi, MD
Assistant Professor of Neurological Surgery and Radiology; Director of Endovascular Neurosurgery Fellowship Program; Director of Undergraduate Neurosurgical Education; Director of Traumatic Brain Injury Basic Science Laboratory
Expertise: Open cerebrovascular surgery and minimally invasive endovascular neurosurgery; the evaluation and treatment of brain aneurysms, arteriovenous malformations (AVMs), vascular tumors, carotid stenosis, and vascular abnormalities of the spinal cord; management and treatment of pituitary tumors; spinal interventional procedures including vertebroplasty, kyphoplasty, and dorsal column stimulator placement. Part of the Comprehensive Stroke Center at UH.
Research interest: Regeneration after traumatic brain injury
Case study: An MRI on a 58-year-old man showed a right frontal AVM, which carries a significant risk of rupture that can cause stroke or death. The treatment involved a non-surgical, minimally invasive procedure that determines which vessels supply the normal brain and which the AVM. Here the AVM controlled the left leg, so if after injecting a drug into specific vessels the left leg was able to move, those blood vessels could be safely closed with a new material called Onyx. This center is one of the few using this lava-like material that moves slowly through and closes blood vessels. The treatments closed the AVM; the surgery that followed was easier with less blood loss. “The patient returned to work,” Gandhi reported, “and can walk well.”
Ira M. Goldstein, MD
Assistant Professor, Neurological Surgery
Expertise: Minimally invasive surgery of the spine, endoscopic diskectomy, the treatment of spinal tumors, kyphoplasty, nucleoplasty, arthroplasty, spinal fusion, biomechanics of the spine and stereotactic radiosurgery of the spine.
Research Interests: Osteomyelitis (infection of the spine), pseudoarthrosis (failure of bone to heal after surgery) and bone augmentation.
Case study: A 47-year-old woman had constant lower back pain and reported numbness and weakness in her legs. She walked with a straight cane for a year and had epidural steroid injections and physical therapy without improvement. An MRI scan showed that her L3 and L4 vertebrae were slipped out of position and that the intervening disk space was completely collapsed. She was a candidate for minimally invasive spine surgery in which Goldstein placed titanium screws into the displaced bones and then pulled these bones back into position, locking them in place and replacing the damaged disk with a synthetic cage and bone graft to permit the bones to grow together. Three months after surgery, the patient experienced an 80% improvement in back pain and a near complete recovery of strength.
Robert Heary, MD
Professor of Neurosurgery
Expertise: Disorders of the spine and peripheral nerves; a full range of conservative and surgical interventions for a wide spectrum of spinal disorders and complex spine reconstruction. Did a fellowship in orthopedics, concentrating on the spine, and is one of few physicians in the U.S. with training in both neurosurgery and orthopedics.
Case study: A 24-year-old female with progressive scoliosis since adolescence developed difficulty with balance and body symmetry. X-rays showed structural thoracic spine curvature and a compensatory lumbar curve. Using a technique he perfected by practicing on cadavers, Heary used screws instead of the usual hooks and rods to straighten the thoracic curve. Screws provide stronger fixation and better correction — and shorter surgery. The lumbar curve straightened itself without intervention once the thoracic region no longer curved.
Research Interests: Directs two independent labs, one for spinal cord injury research. Current work uses both surgical and cellular therapies with a focus on immunological mechanisms. The second focuses on spine biomechanics.
James K. Liu, MD
Assistant Professor of Neurological Surgery; Director, Center for Skull Base and Pituitary Surgery; Director, Brain Tumor Center and Cerebrovascular Bypass Program
Expertise: The treatment of complex brain tumors and skull base lesions, including pituitary tumors, acoustic neuromas, meningiomas, chordomas, esthesioneuroblastomas; minimally invasive endonasal endoscopic surgery, image-guided keyhole microsurgery, and laser-assisted tumor surgery; cerebrovascular bypass procedures for carotid occlusion, complex aneurysms and skull base tumors; microvascular decompression for trigeminal neuralgia and hemifacial spasm.
Case study: A 43-year-old woman had an olfactory groove meningioma at the base of her skull that quadrupled in size over four years to the size of a grapefruit. Her frontal lobes were swollen and severely compressed. If left untreated, this would become life-threatening. Traditional treatment would have meant an open skull base procedure that requires an incision from ear-to-ear behind the hair line with removal of her forehead bone to access her tumor. Instead, Liu performed a minimally invasive surgical technique, called the endoscopic endonasal approach, allowing him to remove the entire tumor without skin incisions or craniotomy. “The patient has completely normal neurological function without any visible scar and is tumor free,” says Liu.
Charles J. Prestigiacomo, MD, FACS
Associate Professor of Neurological Surgery, Radiology and Neurology & Neuroscience; Program Director, Residency in Neurological Surgery; Director, Cerebrovascular Center
Expertise: Cerebrovascular microsurgery (aneurysms, AVM, cavernous malformation, carotid endarterectomy and bypass), endovascular surgery for the treatment of all brain, spinal cord and head/neck pathology (aneurysms, AVM, stroke, tumor, vessel occlusion) and stereotactic radiosurgery for vascular lesions.
Research Interests: Outcomes in subarachnoid hemorrhage, mechanisms of cerebral vasospasm, decision analysis and biophysics of aneurysm formation, history of neurological surgery and medicine.
Case study: A 69-year-old woman presented to her ophthalmologist with headaches and blurry vision. Imaging studies showed an aneurysm impinging on a part of her brain. Because a portion of the artery is naturally embedded in the bone of the skull, the aneurysm eroded through the bone and presented a significant risk of stroke to the patient. The lesion was complex and the surgery high risk, so Prestigiacomo proceeded with a less invasive approach to treatment. He placed a metal strut (a stent) within the vessel along the base of the aneurysm to construct a scaffold. Then platinum coils were placed through the stent into the aneurysm itself, progressively filling it to the point of complete obliteration while preserving the parent artery. “Without this,” he explains, “the patient would have been exposed to high risk with no guarantee that the parent vessel would have been preserved.”